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Tackling Ebola on many fronts

GHI community confronts deadly disease in the lab, on the radio, in story and through relationships

Students in Kabala, Sierra Leone, draw maps about health hazards in their community as part of an Undergraduate Global Health Field Course led by Alhaji Njai. Since June, Njai has prepared bi-weekly radio broadcasts of practical advice to help the community reduce their risk of Ebola. (Photo by Alhaji Njai.)

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Wielding a bi-weekly radio program that tells people in his home village in Sierra Leone how to protect themselves and their families, the University of Wisconsin-Madison’s Alhaji Njai takes his stand against Ebola.

Fear and grief are never far away, as the Ebola outbreak spreads and deaths mount in the small country where it’s easy to know someone who’s infected or has died. “More and more people you know are getting infected, and the system is overwhelmed,” says Njai, a research fellow in the School of Veterinary Medicine who has led undergraduate global health field courses to Sierra Leone. “It’s very, very difficult, especially when your mom is there, your siblings. My family is all there.”

While on the radio, Njai dispels myths, offers practical advice to stop the spread of the disease and tells family and friends they are not powerless against the lethal virus, which the Centers for Disease Control predicts could infect 550,000 to 1.4 million people by January.

UW-Madison’s Alhaji Njai, right, with his former high school teacher Owen Jones, a mentor for students Project 1808 helps with school costs.

“What I want to give them is hope. Yes, it’s a deadly disease, but it’s not hopeless.”—Alhaji Njai

Njai is among a cohort of researchers and physicians in the Global Health Institute (GHI) community who have personally and professionally confronted the outbreak ̶ and are looking for ways to avoid the next crisis.

Virologist Yoshihiro Kawaoka, a professor in the School of Veterinary Medicine and GHI Advisory member, studies how Ebola replicates inside cells, work that is essential to developing vaccines and drug therapies.

Janis Tupesis, director of the UW-Madison Department of Emergency Medicine’s Academic Affairs and Global Health programs and a GHI Advisory member, helped build emergency medical education in Liberia and is part of a group that has received funding from the Paul G. Allen Foundation to provide Ebola relief and return to help build the health care system.

GHI Advisory members Gregg Mitman, Vilas Research and William Coleman Professor of History, History of Science, Medical History, and Environmental Studies, and Rick Keller, professor of Medical History & Bioethics, make clear the colonial roots of the response to Ebola, challenging their students and the community to see more than stereotypes. Mitman will release a new documentary in early December about a U.S. Liberian family in the midst of the crisis.

“Ebola very powerfully points out that we live in an integrated world of animals, humans, ecosystems and infectious agents.”—Christopher Olsen, GHI acting director

Ebola shows how lives are interdependent, says Christopher Olsen, GHI acting director and a professor of public health in the School of Veterinary Medicine, who points to evidence that clearly indicates fruit bats and non-human primates can be infected with ebolavirus and may serve as sources for human infection. “We have to look at the solutions to these types of diseases from these integrated perspectives.”

Health care, emerging disease, politics, posturing and ethics, Tupesis says. “The hard part for people to understand here in the United States is the absolute paucity of infrastructure,” he says. In the rainy season, there are no roads to get equipment to rural communities where there are no health care providers.

Among the many health care workers who have died, the disease quickly took the head of internal medicine and the head of emergency medicine at Liberia’s only academic referral hospital. Tupesis wonders: “How do you backfill leadership?”

Ebola tells researchers and clinicians they must approach disease from multiple perspectives, Goldberg says. “We’ve known about Ebola for many years,” he says. “There have been outbreaks, and this virus is not very different, yet we could not predict the epidemic. If we can’t predict things we know about, we’re not doing a very good job.”

Those fighting Ebola need antivirals, hazmat suits, respirators, and a vaccine to thwart Ebola. The battle also requires a knowledge of the ecology of the infection, including human ecology, Goldberg says. Such efforts require better communication among biologists, social scientists and public health experts.

GHI Associate Director Tony Goldberg’s work takes him to Uganda, where he studies the biology and the interactions between non-human primates and humans to help determine how diseases spread in an effort to prevent the next epidemic.

Goldberg’s research focus is in Uganda, studying primate viruses and how human behaviors might place people and primates at risk of acquiring infections from each other. As he explores how humans contract the diseases and how they spread, he sees the majority of the risk in the interactions between people.

The challenge is to look beyond now to what could be next, says Olsen, a professor of public health in the School of Veterinary Medicine. “What do we not know that we need to know for the future?” His hope is that the public and global health world will recognize the need to understand the basic determinants of disease, taking a One Health approach for the long-term and investing in that type of research and building health care and public health infrastructures.

Unraveling Ebola’s molecular secrets

For Yoshihiro Kawaoka, the fight with Ebola takes place in the laboratory. He works with a biologically-contained Ebola virus that cannot grow in human or animal cells. This virus can grow only in specially designed cells, though it behaves like typical Ebola in this system and can be carefully controlled.

The Ebola outbreak does not lend new urgency to his work because it is always urgent. “Like any scientist, you work on a subject you think is important,” he says. “In the context of an outbreak, you hope what you do contributes to the current environment.”

Yoshihiro Kawaoka, a professor of pathobiological sciences, has been unearthing Ebola’s secrets for 20 years with an eye to developing drug therapies. (Photo by Bryce Richter/ UW-Madison.)

Besides, he’s accustomed to working with influenza. “There are always influenza outbreaks,” he says. “In that sense, the urgency is always there from the beginning.”

An internationally recognized influenza researcher, Kawaoka, who recently won a Breakthrough Award from Popular Mechanics, has also been a leader in Ebola since the mid-1990s. That’s when he realized he could apply his influenza research experience to the deadly disease and was introduced to a reverse genetics technique involving the vesicular stomatitis virus that would allow him to safely do it.

Kawaoka used a vesicular stomatitis virus that lacks a gene and therefore does not grow in normal cells unless it is provided with the missing viral gene product from another source. He used this virus to adapt the technique for use in Ebola virus research. His group ultimately established a technique to generate Ebola virus from plasmids, and to modify and synthesize a mutant Ebola virus that replicates only in specific cell lines, not in normal cells.

“Unless you know how Ebola virus functions and how it replicates in cells, you cannot come up with a rational design of counter measures.” —Yoshihiro Kawaoka

With part of an $18 million in funding from the National Institutes of Health, which he won last summer — before the current outbreak —Kawaoka is leading a study to understand which cell proteins Ebola uses for replication and whether that process can be interrupted. The results will point toward new drug therapies for Ebola and other viruses.

Kawaoka also has applied for funding to restart work on an Ebola vaccine. After eight years of work, his candidate vaccine had protected non-human primates. If funding had not been pulled, he says he would know by now if the vaccine would be possible for human clinical trials.

Science is why Kawaoka chose virology, and the molecular workings of cells continue to fascinate him. But, like today’s students and post-doctoral researchers, his focus has widened and he’s also deeply interested in contributing to public health.

“When I was young, I got into this field because (the science) was very interesting and exciting,” he says. “After many years, I started to feel I really want to contribute to society, to be useful. That’s how I feel.”

Building emergency medicine in Liberia

Friendship took Janis Tupesis, to Liberia eight years ago. He was among the first to join Dr. James A Sirleaf, the Liberian president’s son, in the non-profit Health Education and Relief Through Training (HEARTT) Foundation. He helped establish a fledgling emergency medicine program in a country with high death and disease rates from road accidents, burns, acute infections and other emergency situations.

Tupesis was on the ground, sorting out emergency training priorities, developing curriculum for nurses, medical students and residents, and establishing an emergency medicine residency site for UW Hospitals and Clinics. He saw progress when patients were triaged and the critically ill cared for first. He applauded when nurses understood they could question doctors and call on them when patients sickened.

GHI Advisory member Janis Tupesis (left) spent eight years helping Liberia develop emergency medicine, including working with residents who learned to work with few resources.

“It evolved into this rich and robust training center for our students and clinicians,” Tupesis says. The residents were also learning to work with few resources as they helped build an emergency infrastructure.

Two of the UW emergency medicine residents were in the air on their way to Liberia in March, when Sirleaf called to say HEARTT was suspending all activities. Tupesis found spots for the residents in Ghana.

Ebola has changed everything. “From a professional level and a personal level, it’s all the people you know and have worked with (who have died),” Tupesis says. “The whole thing has been overwhelming. It’s friends and colleagues, not just random people.”

“The hard part for people to understand here in the United States is the absolute paucity of infrastructure.” —
Janis Tupesis

The only glimmer of hope he sees is that this crisis has caused the world to see the need for infrastructure – for training nurses, residents and other health care workers, and building hospitals and clinics. “Funding infrastructure is not sexy,” he says. With pediatric vaccines or delivering HIV medications, results are quickly measurable. It’s harder to measure tangible outcomes when you’re training pre-hospital care providers.

UW-Madison’s Janis Tupesis, right, celebrates with residents after they completed their oral board exams. The physicians in the center of the photo, Samuel Brisbane, director of the Emergency Department, and Emmanual Borbor, director of Internal Medicine, are among the health care workers who have died in the outbreak.

While emergency medicine residents won’t be going to Liberia this year, Tupesis is among a group funded by the Paul G. Allen Foundation to provide Ebola relief and help rebuild health care in Liberia. Rebuilding is a must, Tupesis says: “If you really think about it, in a well-trained, well-run infrastructure, it only takes one doctor you trained to say, “I think this is Ebola” and quarantine the person, and it’s over.”

The danger of what we don’t know

Where are our blind spots, the prejudices we carry, maybe unknowingly, when it comes to Africa or any other place that is not our own? What are the things that we don’t know that would dramatically change how we see?

Rick Keller (Photo by Bryce Richter.)

Rick Keller invites his students in “International Health and Global Society” to look at two photographs.

One shows a group of three African youth carrying a dead antelope suspended on a branch. The UW-Madison students see bush meat, something bad, dangerous, unhealthy and unsanitary.

The second photo is of a Wisconsin youth holding the head of a dead deer up by its antlers. The students see game, the great outdoors, fall in Wisconsin, protein for the winter.

The students immediately understand the paradox, and, then, Keller explains how many more people die of malnutrition than Ebola in many African countries, how the disease pales in the face of hunger that will kill many, many more.

As medical historians, Keller and Gregg Mitman bring the perspective of history and the power of story to the Ebola crisis.

Keller has worked in North Africa and his interest is looking at the history of global health in the 20th and 21st centuries. This crisis is rife with historical precedents.

The British and French empires responded to epidemics with quarantines and military intervention. In Sierra Leone and Liberia, countries recently torn by civil war, families learned that strangers in military vehicles are not always friendly.

“People were taken away (during the civil war) and they died. How different is that from taking the ill into custody and only returning some of them, or being forced into quarantine and having your home and possessions burned?”—Rick Keller

Knowing the recent history and a long-term history of medical exploitation belies the image the Western press has given of primitive Africans who don’t accept help, he says.

Disease is never just biology

“What Ebola makes visible are the fault lines,” Mitman says, and those fault lines – of economic, social and health inequities – are clear every time his “Environment and Health” class meets. “Every topic comes back to Ebola,” he says.

On a recent Wednesday, the topic was the history of tropical medicine, organized around the drive to build an empire, and the important part it played in European colonialism in Africa. The class looked at the shift from quarantines, which restrict trade, to sanitary reform.

Immediately, classroom discussion shifted to the Ebola patient in Dallas.

UW-Madison’s Gregg Mitman, left, with camera person Alex Wiaplah, filming a conversation with Emmanuel Urey and his father-in-law in Greenville, Liberia, for a new documentary.

“If Liberia was a strong trading partner for the United States, I think we’d be seeing a different discussion about isolation and quarantine,” Mitman says. “Just look at SARS.” The 2003 outbreak of Sudden Acute Respiratory Syndrome in southern China did not shut down travel to and from China.

“Disease is never just biology,” says Mitman, who was in rural Liberia in June filming a documentary. Ebola had already claimed lives in nearby Guinea and in Liberia, where free blacks from America settled in the 1820s.

In the months that followed, Mitman has found himself reliving the history he teaches – watching as once again fear brands West Africa as a deadly, dark nation. Concerned that few were heeding the Doctors Without Boarders calls for help, Mitman wrote an article for the New England Journal of Medicineexploring the history of Western medicine in Africa.

It is a history fraught with fear, extracting riches and exploiting indigenous people, with no concurrent effort to build infrastructure that would improve public health. Even now, he says, multinational corporations are receiving land concessions for agriculture and minerals, but no one is investing in the medical infrastructure.

Mitman’s job, as he sees it, is to share stories that counteract the stereotype of “West Africa as a place of incompetence, irrationality and disease.” He celebrates instead the visual and hip-hop artists creating Ebola public service announcements and honors the burial workers who have not been infected despite months of working with the dead. He has graduate students in African studies searching and collecting ephemeral Liberian social media and news sites to document how Liberians are responding in their own words.

He’s also filming a short documentary on Ebola, following a Liberian family in Madison, Wis., with footage from Monrovia that will be released in early December.

Hope is a noun

Ebola has not reached Alhaji Njai’s hometown in a remote area of northern Sierra Leone. The first cases in the district, however, were diagnosed Oct. 15: It was the last district to report the disease.

Tourists seek out this region of forests, mountains and grasslands in a district that struggles. More than 70 percent of the people live in poverty; almost 90 percent are illiterate, and there’s one district doctor for 265,000 people. The district’s single ambulance often cannot travel on impassable roads.

Learning about health and hygiene is intergenerational when Alhaji Njai leads the UW global health field course in Sierra Leone.

“The statistics are really against this environment,” says Njai, whose parents sent him to school and allowed him to stay as he won scholarships to pay for high school and college. After the 10-year Sierre Leone civil war, he organized Project 1808 to pay tuition, buy supplies, mentor elementary and middle school students and involve them in community projects. The 56 students recruited in 2011 remain in school, and they have passed their entrance exams with the best results in the district.

Njai also led two UW-Madison undergraduate field courses to Sierra Leone, partnering UW-Madison and University of Sierra Leone students, immersing them in the culture, politics, social and health systems, then working in the community to implement ideas. More than 400 Kabala school-age children attended this year’s health camp. In 2013, the curriculum included hand washing, cleaning and waste management. This year, the children learned about the symptoms of Ebola.

Students in northern Sierra Leone learn about hygiene and the signs of Ebola infection during a global health field course in spring 2014.

In June, the Kabala radio station called Njai. “Please. Please. Please. Talk to our people.” As a son of the community with no government ties, Njai is a trusted voice to talk about prevention and sort through rumors and remove fears and misconceptions. He is also on theVoice of Islam in Freetown, the capital.

Hope is a noun as Njai translates his bi-weekly radio programs into five local languages to let villagers know how to protect themselves and their families against Ebola. “Ebola comes from direct contact,” he says. “Anything you can do to minimize that direct contact, you’re in much better shape. It just keeps going if you can’t minimize the infection rate.”

His advice is practical: If you notice changes in your body temperature isolate yourself. You could save yourself, your family, your community by saying don’t come close to me. Talk about Ebola with your family. Identify an isolation room. Stock up on food and chlorine bleach. Use plastic bags to protect your hands if you have no gloves. Learn how to take care of someone because care from outside will not come quickly. Practice what you will do as a family, as a community.

“Anything you can do to minimize that direct contact, you’re in much better shape. It just keeps going if you can’t minimize the infection rate.”—Alhaji Njai

The radio station called in late October to tell Njai people are responding. The community trusts him.

Njai sees himself as a teacher and a cheerleader, doing his best to keep his family and community safe. “What I want to give them is hope,” he says. “Yes, it’s a deadly disease, but it’s not hopeless.”

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